Billings Clinic



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Training Center

2800 Tenth Avenue North

PO Box 37000

Billings, MT 59107-7000 | |

|Name (with credentials if applicable): |

|Mailing Address: |

| |

| |

|Phone: home |

| Work |

|Fax: |

|Email address: |

|AREA OF CERTIFICATION |DEGREE OF CERTIFICATION |DATE OF INITIAL CERTIFICATION |

| | | |

|BLS |( Instructor | |

| | | |

| |TC Faculty | |

| | | |

| |Regional Faculty | |

| | | |

|HEARTSAVER 1ST AID |( Instructor | |

| | | |

|ACLS |( Instructor | |

| | | |

| |TC Faculty | |

| | | |

| |Regional Faculty | |

| | | |

|PALS |( Instructor | |

| | | |

| |TC Faculty | |

| | | |

| |Regional Faculty | |

Please include a copy of both sides of your current instructor and provider cards in each area

for which you are currently certified. (Only for 1st time instructors)

Please return completed registration form to:

Mary Walser

Training Center Assistant Coordinator

Billings Clinic

PO Box 37000

Billings, MT 59107

For Training Center use only

Registration fee: _____Yes______________ CTC instructor # _____________________

Copy of card(s): _____Yes______________ Date enrolled

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